Tonsillectomy
 
 
1. Why Don't The Doctors Take Out The Tonsils And Adenoids Like They Used To?
No practice involving the health care of children has excited more controversy among doctors than has the surgical removal of the tonsils and adenoids. Tonsillectomy and adenoidectomy (often called T&A) continues to draw large amounts of attention. Despite some decline in the total number of surgeries performed each year, there still remains a high rate of performance of T&A surgery. This is attributed to the firm belief in the minds of doctors and parents that T&A surgery is a treatment of importance and value.

Tonsillectomy has been a surgical procedure performed for thousands of years. Over the years, widespread abuse of the operation led to growing concern over its usefulness. At one point, certain communities promoted wholesale surgery for entire populations of school children in public school buildings. Skepticism regarding the true indication for subjecting such large numbers of children to tonsillectomies began to be voiced in the 1930's.

In the 1970's, more clearly defined medical indications for surgery began to be developed. However, there still remain wide differences of opinion concerning how extensive, severe and long-standing the problem needs to be in order to justify surgery. The two major indications for tonsillectomy are 1) recurrent infections and 2) airway blockage.

Recurrent tonsillitis (infections of the tonsils) used to be the main indication for tonsillectomy. The surgery prevented the complications of Strep tonsillitis. However, the availability of antibiotics has markedly decreased the need for tonsillectomy. Over the years, it has been noted that although Strep tonsillitis could be treated successfully with antibiotics, some children had frequent, recurrent infections causing illness despite good antibiotic treatment. Antibiotics have also not been as successful at treating severe recurrent tonsillitis which is caused by bacteria other that Strep. Depending upon the frequency and severity of these recurrent infections, some children suffered from recurrent illnesses and lost long periods of valuable time from school.
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2. Why Would My Doctor Take Out Adenoids But Not Tonsils?
While a T&A is often thought of and often carried out as a combined operation, each portion of the operation, that is the tonsillectomy portion and the adenoidectomy portion, requires attention separately to determine its particular need to be done. The practice of performing both operations when only one is indicated just to take advantage of the hospitalization and anesthesia is not a recommended practice. Separate indications must be met.
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3. Who Gets The Surgery?
Although no single, rigid criteria is appropriate for all patients, many insurance companies now require that these same guidelines be met before approval for a tonsillectomy will be given. The basic criteria doctors use to consider recommending a tonsillectomy for recurrent tonsillitis is:

1. 5-7 infections in one year

2. 4-5 infections each year for 2 years

3. 3 infections each year for 3 years

Each infection must be evaluated and treated by a doctor since many children will have self-limiting cases of viral tonsillitis which require no specific treatment.

Each treated tonsil infection should also be associated with one or more symptoms, such as fever greater than 101 degrees, enlarged glands in the neck, pus on the tonsils, or a positive Strep culture. The second major indication for tonsillectomy is airway obstruction.

The tonsils can progressively enlarge until they block the airway and interfere with breathing. Many of these children have no history of tonsil infections. Chronic airway obstruction has become the most common indication for tonsillectomy. In this instance, it is usually combined with an adenoidectomy to improve breathing through both the nose and mouth. Children with airway obstruction may progress to the point of developing obstructive sleep apnea, which can lead to chronic problems with the heart and lungs. More details about sleep apnea can be found in the "Respiratory problems" section of this site.

Other indications for tonsillectomy, which are not as common, include:

1. An abscess around the tonsil (peritonsillar abscess)

2. Abnormal development of the teeth and jaw bones due to airway blockage

3. Suspected tumor of the tonsil

4. Chronic bad breath.
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4. Does My Child Have To Stay In The Hospital?
A routine tonsillectomy is usually performed as an outpatient surgery. However, children under the age of 3 years and those with symptoms of severe airway obstruction may be considered for overnight observation in the hospital.

Children with sleep apnea definitely need to be hospitalized overnight with possible monitoring in the intensive care unit. Other factors, which may prompt an overnight hospitalization, include severe asthma, diabetes, cystic fibrosis and patients with bleeding disorders. Your child's doctor will determine if an overnight stay is needed and will get the authorization from the insurance company before surgery.
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5. How Do They Take The Tonsils Out These Days?
The tonsillectomy operation takes approximately 30 minutes to perform and is done while your child is asleep under general anesthesia. A special instrument holds your child's mouth open for a clear view of the tonsils. The entire procedure is performed through the mouth. There are no scars of the face or neck. The actual technique for performing the tonsillectomy varies with each surgeon depending upon his training.

Some of the most common techniques include:

1. The standard steel knife

2. The laser

3. The hot knife or electric cautery

4. The snare (a wire placed around the tonsil)

5. The coblator (radio frequency ablation)...Dr White's preference
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6. When Can My Child Go Back To School And Back To Sports Practices?
The expected recovery time after a tonsillectomy is about one week. Your child may have severe pain, which requires the use of narcotic pain medications. Because of this pain, you will need to constantly keep encouraging your child to drink juices, eat Jell-O or sherbet to prevent dehydration. Dehydration is the most common complication of tonsillectomy surgery. Ice packs to the upper neck can be soothing.

Ear pain is very common, in fact it can be worse than the throat pain in some children. This ear pain is due to irritation of the nerve, which goes up to the ear.

Giving your child sugarless gum to chew after surgery is an effective way to get him to swallow and use the throat muscles. This tends to promote faster healing. Children generally miss a full week of school and should not participate in gym class or other strenuous activities such as T-ball, ballet, gymnastics, karate, and cheerleading for a full two weeks (14 days) after surgery to allow for adequate healing and decrease the risk of postoperative bleeding.

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7. Is My Child Going To Bleed After Surgery?
Bleeding is the most feared complication after a tonsillectomy. It is not very common and ranges from usually 2-5% in children. Bleeding can occur shortly after surgery, but it most commonly happens 7-10 days after surgery. Bleeding is more common in children who were not taking in adequate amounts of liquid and developed dehydration or allowed the healing scab covering the surgical area to dry up. Slight bleeding may occur as the scab separates from the wound. This is usually controlled with ice packs to the neck and drinking cold liquids to clamp down the bleeding blood vessels.

If the ice packs do not stop the bleeding, you will need to notify your child's doctor and plan to proceed to the emergency room. Your child may need to be taken back to the operating room where the bleeding blood vessels can be cauterized. Blood transfusions are not commonly needed. The risks of your child undergoing a tonsillectomy are those related to anesthesia and those directly related to the surgery.

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8. Is Anesthesia Risky For My Child?
Prior to surgery, you should meet with the anesthesiologist who will be putting your child to sleep. You will then have an in-depth discussion about the risks from anesthesia. The major risks from anesthesia include abnormal heartbeats, injury to the voice box and teeth, inhaling mucous or stomach acid into the lungs, and a rare reaction to anesthesia called malignant hyperthermia.

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9. What Are The Risks Of Taking Out Your Tonsils And Adenoids?
The major risks due to the tonsil surgery include dehydration which may need fluids to be replaced into the veins, bleeding which may require surgery to control or a blood transfusion, swollen tissue in the nose and mouth causing airway blockage.
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